Clozapine clinic

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member2721

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Does anyone have experience working in a clozapine clinic? Anyone have thoughts on the patient population, the objective and subjective pearls of using this medication? Much appreciated.

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I work at an SMI clinic and I have a few patients on Clozapine. It is a problematic medication to use if non-adherence is a problem (which almost everyone with Schizophrenia) due to safety issues. The best patients on Clozapine have 24 hr support, strong family support, or are independent and semi- obsessive about taking their medications as prescribed. I tend to use more long acting injectables ie. Invega Sustenna, Risperdal Consta, Abilify Maintena, Fluphenazine decanoate, and haloperidol decanoate. The non-adherence issues are mostly related to the cognitive decline. Many want to take the meds and feel they need to take the meds, they just do not remember or are too disorganized.
 
What's been your experience with Abilify, either oral or Maintena, for psychosis control? I've been mostly taught that it is an inferior antipsychotic when compared to Risperdal or Zyprexa for example. Obviously studies show that it works, which is why it's approved, but does it REALLY work?
 
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I would disagree with the description of every patient with schizophrenia being nonadherent. I think the challenge is that by the time the patient is on clozapine, it is because they likely have symptoms that are refractory to most other medications, which make them a clinical challenge. I certainly wouldn't restrict clozapine to people under 24 hour a day care; clozapine is the type of medication that prevents patients with schizophrenia requiring 24 hour a day care. it has about the best evidence base of any antipsychotic. Many psychiatrists did not get adequate experience with using clozapine in residency, which leads to it's under prescription in the community.
 
I have a good handful on Abilify Maintena. 400mg IM once a month. Works well for Schizophrenia and has a much cleaner side effect profile. Less weight gain, less sedation. I was taught the same thing in med school and residency. Abilify is solid in my experience.
 
What's been your experience with Abilify, either oral or Maintena, for psychosis control? I've been mostly taught that it is an inferior antipsychotic when compared to Risperdal or Zyprexa for example. Obviously studies show that it works, which is why it's approved, but does it REALLY work?

It is an inferior antipsychotic to olanzapine or risperidone per the Leucht et al. multiple treatment meta-analysis but that doesn't mean it doesn't work or doesn't have a place in the treatment of schizophrenia for those who haven't tolerated other neuroleptics. There is a clear inverse correlation between efficacy and tolerability for these drugs. The worse the side effects (and particularly the fatter and sleepier they make you) the better neuroleptic they are! However, it is a reasonable drug to use in an outpatient setting. The problem with using inpatient is that it has a long half-life because of its active metabolite dehydro-aripiprazole (about 94 hours) so it takes about 19 days to reach steady state. That means that all that crazy uptitrating that happens on the inpatient unit is worthless and makes the drug harder to use for acutely decompensated patients. But in the outpatient setting entirely reasonable to use as long as you're not silly enough to try increasing it every week and scratching your head about why not much is happening.

There was also a lot of hype generated because of its novel action as a D2/5-HT1a partial agonist so I think people had high hopes for it and so it has been devalued perhaps more unfairly than it should. At the same time, it has aggressively gone after FDA approval and been successful for multiple indications on the submission of fairly flimsy date (bipolar maintenance approval on only 6 months worth of data anyone?)

It also seems to reverse the metabolic effects of other antipsychotics like clozapine and olanzapine. So it is a favorite add-on for clozapine as much for maangement of metabolic syndrome as augmentation. Not that we should be encouraging dual neuroleptic usage...
 
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the only thing I will say about clozapine is an oft-forgotten/overlooked side-effect is the development of OCD. Which is very interesting in an of itself.
 
It is an inferior antipsychotic to olanzapine or risperidone per the Leucht et al. multiple treatment meta-analysis but that doesn't mean it doesn't work or doesn't have a place in the treatment of schizophrenia for those who haven't tolerated other neuroleptics. There is a clear inverse correlation between efficacy and tolerability for these drugs. The worse the side effects (and particularly the fatter and sleepier they make you) the better neuroleptic they are! However, it is a reasonable drug to use in an outpatient setting. The problem with using inpatient is that it has a long half-life because of its active metabolite dehydro-aripiprazole (about 94 hours) so it takes about 19 days to reach steady state. That means that all that crazy uptitrating that happens on the inpatient unit is worthless and makes the drug harder to use for acutely decompensated patients. But in the outpatient setting entirely reasonable to use as long as you're not silly enough to try increasing it every week and scratching your head about why not much is happening.

There was also a lot of hype generated because of its novel action as a D2/5-HT1a partial agonist so I think people had high hopes for it and so it has been devalued perhaps more unfairly than it should. At the same time, it has aggressively gone after FDA approval and been successful for multiple indications on the submission of fairly flimsy date (bipolar maintenance approval on only 6 months worth of data anyone?)

It also seems to reverse the metabolic effects of other antipsychotics like clozapine and olanzapine. So it is a favorite add-on for clozapine as much for maangement of metabolic syndrome as augmentation. Not that we should be encouraging dual neuroleptic usage...

Cool, thanks! Will have to read up on the Leucht et al. study. My go to for long-acting injectables are Risperdal Consta/Invega Sustenna, and when I heard about Abilify Maintenna I thought to myself "pff… really? Abilify sucks for psychosis control." Guess I need to be a little more open minded.
 
Are Clozapine clinics common? I don't think I've heard of the concept, and I'm not sure I understand why patients put on this medication should go to a special clinic for it instead of seeing their usual psychiatrist.

My go to for long-acting injectables are Risperdal Consta/Invega Sustenna
No love for Haldol or Prolixin? Saves tons of money.
 
Are Clozapine clinics common? I don't think I've heard of the concept, and I'm not sure I understand why patients put on this medication should go to a special clinic for it instead of seeing their usual psychiatrist.
I fear that the "clozapine clinic" concept is being put forward by a psychiatrist who is willing to completely let go of the concept that s/he is a physician in addition to being a psychiatrist. I have a hunch that you'll find such psychiatrists underprescribe Lithium when it's a rational choice and do less standard practice follow-up labs.
No love for Haldol or Prolixin? Saves tons of money.
Ditto this.


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I fear that the "clozapine clinic" concept is being put forward by a psychiatrist who is willing to completely let go of the concept that s/he is a physician in addition to being a psychiatrist. I have a hunch that you'll find such psychiatrists underprescribe Lithium when it's a rational choice and do less standard practice follow-up labs.

this seems rather cynical. it makes very practical sense to have all patients treated with clinic in one clinic where everyone is having their weekly labs, and there is a pharmacist responsible for coordinating all the patients, and they can be better monitored. a clozapine clinic is really a "treatment resistant psychosis" clinic and in academic settings it does make good sense to have specialized services where things can be streamlined and dedicated resources/staff for this. It is not like psychiatrists working in these clinics spend all their time doing this, more likely they will spend a day a week or so doing this kind of work. In academic settings they probably serve an educational role in training staff in using clozapine and may have some research purpose too.
 
I have no problem with a "treatment resistant psychosis" clinic. This is a much different than a Clozapine Clinic. The former recognizes a severity of illness, the latter prejudices to a particular modality, which is poor strategy.

Clozapine is not a boogie man, it's an extremely effective treatment that requires close attention. My hunch is that folks that forego Clozapine for psychosis are exactly the same folks that are slow to use Lithium for bipolar or MAOI or nefazodone for depression. I'm uncomfortable with clinics limiting their offerings based on the fact that some of the best treatments available for severe illness require the most attention from clinicians. This is the case with most fields in medicine. And the requirements for monitoring clozapine are minimal by comparison.

I appreciate the counter argument, but I'm pretty comfortable it's not cynical.


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I have no problem with a "treatment resistant psychosis" clinic. This is a much different than a Clozapine Clinic. The former recognizes a severity of illness, the latter prejudices to a particular modality, which is poor strategy.

Those concerns make sense but don't really apply to how clozapine clinics work (at least the ones that I am familiar with). For example, at our VA, patients who are started on clozapine after failing other treatments are mostly seen in the clozapine clinic at that point. It's not like some people who seem very sick are allocated there - so there is no real 'prejudice'. Once in the clozapine clinic things are well set up for easy monitoring, etc., but people can still be changed to other medications if it becomes clinically indicated.
 
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No love for Haldol or Prolixin? Saves tons of money.

Oh sure, but I've been working more with the adolescent population lately and usually go with atypicals first for them. I've used Haldol and Prolixin dec more at the VA, where the non-formulary issues are more of a pain and it's just easier to go with Haldol Dec or Prolixin.
 
I worked in a community treatment resistant service and found it a very rewarding experience. My experience was that clozapine was actually suitable for some people that were extremely disorganised - a lot of effort needs to be put into the initial couple of months (e.g. daily medical visits) but once people get into the habit there could be great improvements to the extent that they were able to manage meds independently.

Here's a nice paper describing how to operate that type of clinic:
http://onlinelibrary.wiley.com/doi/...ionid=A353A54BCE2B02A2D824FAA45616CA7D.f03t01
 
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